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9.29 pm
Lord Carlile of Berriew: My Lords, I declare two interests: the first as a patron of a small but fascinating charity in the West Midlands called No Panic; and the other as president of the Howard League for Penal Reform, which deals with and advises many people who suffer from mental illness while in custody. I congratulate my noble friend Lady Tonge on asking this Question and securing this debate on a very important subject.
There is nothing new about CBT, except perhaps the label and considerable sophistication of techniques. Were he still living, my father would now be 104 years old; he was a general practitioner in an industrial Lancashire town. Despite having spent two years of his high school education in Vienna, he generally regarded psychiatrists as a visitation of the devil. However, he spent an awful lot of his time talking to his patients and we, his children, were there because we lived in the surgery; we lived his life with him. He used to say, as advice for our future, “Just remember: people who don’t eat want to eat, people who can’t go to school want to go, people who are completely unable to work because of a mental condition really want to go to work, and those in that terrible category of agoraphobics want to go out and enjoy life. It is just that they can’t”.
The therapies that my father, and many old-fashioned general practitioners, applied in such places when the local economy and culture collapsed—when the cotton industry was destroyed, and people were suddenly putting together gas cookers rather than enjoying the camaraderie of the cotton mill—all contributed to his powerful belief, which he certainly instilled in his children, that talking to people about their problems helps an awful lot, and probably a great deal more than pharmacology. A starting point in any discussion of mental illness is, surely, that it must never be regarded as a second-division form of illness.
The noble Lord, Lord Layard, has made a great contribution to the argument in that mental illness is an illness like any other, and needs to be treated with the same serious attention. We know, because we all have friends and relatives who have suffered from depression and other mental conditions, that it knows no class distinction, belongs to no one political party—it probably belongs to them all—and sees wealth as no barrier. There is no quick fix. We should not wed ourselves to any one solution. The old-fashioned Jungian/Freudian divisions are to be avoided in CBT, as in anything else. We have to make the best of the cocktail of cures that is available—on a subjective basis, of course.
Anyone who has ever been close to a seriously mentally ill person, whether they are suffering from phobia, depression, an eating disorder or anything else, knows how tempting it is to think and sometimes, foolishly, to say, “Oh, just pull yourself together and get on with life.” However, before they reach anything like a “pulling themselves together” situation, people suffering from mental illness, like people with serious physical illness, need something and/or someone else to pull them together sufficiently to progress to full recovery. Between wanting to be better and starting to be better, there is a large space where cognitive behaviour therapy has an important role to play.
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We must also not forget the cost of failing to deal early with mental illness. It merits repeating again and again that it has a terribly high mortality rate. The mortality from most illnesses is at the hands of the illness; the mortality from mental illness is usually at the hands of the sufferer. It produces frequent self-harming scars that stay with the sufferer for life, a refuge in dangerous substances, and a reduction in revenue through inability to work. For some, as the Howard League knows only too well, it produces incarceration in prisons and young offender institutions. Shockingly, about half those incarcerated there are suffering from diagnosable mental illnesses, but many are not being treated for them. This is no exaggeration of the morbidity of recognised and easily diagnosable conditions; it is a fact.
What does CBT offer? Not a miracle—it may be completely wrong for some cases—but it at least offers cheap, early intervention. There is plenty of evidence, for example, that early, non-pharmacological intervention in teenage anorexia and depression, which destroy many young lives and hold those people back for years, can result in total recovery and a successful adult life. There is evidence, too, from those GP practices around the country that have very imaginatively taken on talking therapy psychotherapists as part of the apparatus of their practices that the recovery of patients is quicker, less reliant on drugs and less liable to secondary and tertiary referrals. The recent Royal College of Psychiatrists study by Muñoz-Solomando, Kendall and Whittington, provides powerful and peer-reviewed support for the use of CBT in many child and adolescent mental health cases, including cases of OCD, post-traumatic stress disorder and even attention deficit hyperactivity disorder. The evidence from that study is that when people are in groups, when they are able to talk to each other with the guidance of a psychotherapist using CBT techniques, recovery can be hastened dramatically.
NICE was absolutely right in recommending, as the first line in child and adolescent mental health, that there should be non-pharmacological approaches. I respectfully agree with the noble Lord, Lord Layard, that there are great merits in this and that there is evidence of such a programme being rolled out. However, I share the view of my noble friend that it is being done too slowly and that it should reach the outer reaches of this country as quickly as possible. I shall say a word about rurality in a moment.
There is remarkable evidence that a combination of CBT and Fluoxetine, a tried and tested substance, appears to reduce the risk of self-harm for depressed children and adolescents. So the news that CBT sends out is good. It is so good that I offer one plea to the Minister to which I hope she will respond. There should be far more of it in prisons and young offender institutions. Those are places where it can be tried, tested, made available and used on an everyday basis. You are guaranteed the co-operation of the patients: they are captive—they have nothing else to do, they have no choice. What better cohort to cure than people who are already costing us at least £45,000 a year to keep in custody?
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This presents the most remarkable value against hospital admission. I went to a hospital a couple of years ago where I was told that a seriously ill adolescent with a mental health problem was costing up to £145,000 a year to keep in hospital. It is probably a good deal more now. Early intervention might avoid some of those cases.
This provision should be made available throughout the United Kingdom. I know that the Minister does not have responsibility for Scotland and Wales. I have an interest in Wales because I used to sit in the other place for a Welsh constituency. The availability in rural parts of England, as in rural Wales, is very limited, particularly when there is a great need for the therapies to be given by people qualified to give those therapies and not others. Occupational therapists are not necessarily very good at psychotherapy, and vice versa. It needs to be accurately targeted and used.
Rural areas are very neglected in mental health provision, but there is plain evidence of need. I have a niece who runs a charity for the Church of England which deals only with depressed and suicidal farmers. They are just an example of a cohort living in the countryside, often very isolated, which needs to have this sort of therapy available. I applaud the computerised version of this therapy; it has a great deal to offer, although I do not think we should spend a huge amount of time on it because it is a small part of a big subject.
My final plea is this: let us keep mental health provision above party politics.
9.39 pm
Baroness Verma: My Lords, the noble Baroness, Lady Tonge, has given us an opportunity to raise a range of serious questions. Through my business in the care sector—I declare an interest—my staff constantly face people suffering mental health issues.
We are all aware of the debilitating effects that depression, chronic anxiety and other matters related to mental health can have on our ability to carry on with our lives as normally as possible. We are also aware that many people are affected by some form of mental health issue in their lifetime. I shall repeat and reflect on many of the remarks made by the noble Baroness, Lady Tonge, and other noble Lords.
NICE has recommended psychological therapies for people with a range of mental illnesses, but reports show that 86 per cent of people with schizophrenia are still not getting any treatment. We all agree that psychological therapies are not a one-size-fits-all solution, but for many people there are clinical benefits and, in the long term, there is a cost saving to the Government. NICE recommends CBT as the treatment of choice for people suffering from post-traumatic stress disorder, OCD, bulimia nervosa and clinical depression.
As the noble Baroness, Lady Tonge, said, evidence shows that the number of cases of mental illness and suicide increases with rises in unemployment, repossession of homes and uncertainty about the future. All these factors have a huge impact on how families and communities cope. Researchers have calculated that we will therefore see a rise by at least 26 per cent in the
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In light of this predicted rise in the number of people suffering from some form of mental health problem as a consequence of the recession, how many cognitive therapists on top of the promised 10,000 do the Government expect will be needed and what are the Government doing to meet the shortfall?
In 2008, 141,000 people claimed incapacity benefit for mental health-related illnesses. Government research shows that 69 per cent of those people were unable to access occupational health through their employer while in employment. What are the Government therefore doing to ensure that employers are aware of initiatives that could help people with mental health problems in their employment? How much money has been spent on providing this resource?
How many people have been treated with CBT since 2006 and is there any information to show the cost benefit to the health service? Phil Hope said in another place that,
- “there will be significant cost savings to the national health service by implementing Improving Access to Psychological Therapies services by reducing pressure on specialist psychology services in mental health trusts and reducing inappropriate referrals made to acute hospital trusts for people with medically unexplained symptoms”.—[Official Report, Commons, 24/11/08; col. 909W.]
How much will the Government have spent on implementing IAPT by 2011?
If primary care trusts are obliged to provide funding for NICE-recommended computerised CBT packages where clinicians want to use them but decisions about care provision are made by individual PCTs, what are the Government doing to end the postcode lottery of access to computerised CBT services and so enabling access for the rising number of people who want them?
While we recognise the benefits of CBT, without adequately trained psychologists, psychotherapists and nurses, it will be impossible to meet any government targets for service provision. The Government recognise that an extra 10,000 therapists are needed, so can the Minister say when they anticipate reaching this target? Are there figures to show the ratio of people with GP-diagnosed mental health problems to therapists in each PCT area? I ask because it is estimated that PCTs have purchased only 15 per cent of the treatments required. Meanwhile, people are put on lengthy waiting lists at a cost of around £300 million per year. How many people are on the waiting list for cognitive therapy in each PCT and how many are receiving treatment? How many community mental health teams in each PCT offer CBT?
I shall turn briefly to children. One in 10 of all five to 16 year-olds have some clinically significant mental health difficulty. Sadly, only one-quarter of them receive specialist help. What are the Government doing to act on the recommendation of the report A Good Childhood that IAPT is rolled out for all children as well as adults?
The debate cannot have a narrow focus on whether therapy works or not. It is widely recognised that there will be those who do not benefit from CBT. However,
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This is a subject that demands a raft of questions and of course recognition that different people need different treatments. Unfortunately, time is not on our side. I would very much like to hear the Minister’s response to the questions raised in this interesting debate.
9.45 pm
Baroness Thornton: My Lords, I congratulate the noble Baroness on her success in securing this debate on such an important and timely subject as psychological therapies. This is a matter in which my right honourable friend the Health Secretary has taken considerable interest in the last few years.
The Improving Access to Psychological Therapies programme is the focus of major investment by both the Government and the NHS. My right honourable friend Alan Johnson announced annual funding rising to £173 million—that is the first question answered for the noble Baroness, Lady Verma—by 2010-11, to improve the care on offer to people suffering from depression and anxiety disorders. This investment was warmly welcomed by all the major charities representing people who use mental health services, as well as the key professional bodies of psychological therapy practitioners from a wide range of disciplines. I pay tribute to my noble friend Lord Layard for his important work in this area; his remarks were welcome and positive, and we know that he is watching us in this matter. I take his point about funding issues; in many ways, I was rather expecting the noble Baroness, Lady Tonge, to berate me about such matters, too.
The overall aim of this investment is to help the NHS implement guidance from the National Institute for Health and Clinical Excellence—NICE—relating to effective evidence-based treatment for depression and anxiety disorders. The guidance outlines appropriate treatment arranged in a series of steps. Each step relates directly to specific and measurable levels of depression or anxiety disorder. Each step offers clinicians a number of effective treatment options, which a practitioner and a patient will discuss and agree on the most appropriate.
Computerised CBT, specifically Beating the Blues, is one of the indicated treatment options for people with mild depression. However, NICE is currently in the process of reviewing its guidance on the treatment of depression and recently published a consultation document which broadens the range of effective computerised CBT programmes to include many that do not incur a cost to the NHS.
Baroness Tonge: My Lords, could the Minister tell me, before she goes on, why the original computerised CBT approved by NICE had so little take-up when the need out there was so desperate?
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Baroness Thornton: My Lords, it might have been the cost. It is vital that people using computerised CBT are supported by trained therapy workers; it could be that it was a question of putting together packages. Evidence shows that it is ineffective if no trained support is given. My noble friend Lord Layard outlined the issue concerning CBT much more eloquently than I did, and was supported by the remarks of his noble kinswoman.
I take issue with the idea that this is a postcode lottery. This representation of how NICE guidelines work is incorrect; the current guidelines mean that PCTs have to make Beating the Blues available if their clinicians prescribe computerised CBT for their patients. If clinicians in consultation with individual patients do not prescribe computerised CBT, clearly there will be no need for the PCT to provide it. So there is no more a postcode lottery here than in any other choice between recommended treatments. There is consultation between the clinician and patient.
To provide the full range of NICE recommended treatment options, the programme will initially train a new workforce of 3,600 therapists. Initially, this training will focus on cognitive behavioural therapy and the routine collection of patient-reported outcomes at every session. In November last year, we published our statement of intent to broaden the programme’s approach, working towards ensuring that all patients have a choice of evidence-based psychological interventions by extending the skills of these new therapists as the services mature.
The programme was initially piloted in Doncaster and Newham, as noble Lords have said. Both areas succeeded in dramatically cutting waiting times and brought half the people they treated to measurable recovery. They also increased the number of patients who were in work by 5 per cent. The pilot sites demonstrated success in reaching and providing effective treatment to previously hard to reach groups.
The NHS has embraced the programme with enthusiasm. The original plan was to establish 20 new services in 2008-09, and in fact 35 services are now up and running. The original plan was to train 700 new therapists in the first year, and in fact, over 800 trainees have joined the new workforce. Later this year, another 81 PCTs will establish services with around 1,700 more trainees. On 8 March, my right honourable friend the Health Secretary announced an additional £13 million for 2009-10 to speed up the availability of psychological therapies for people with mental health problems due to the economic downturn. This extra funding will be used largely to enable employment and psychological therapies services to work closely together to meet the specific needs of individuals who have lost their jobs or are at risk of doing so in these difficult times.
I will now refer to particular points raised by noble Lords and I apologise if I am not able to cover everything, particularly the very long list of questions asked by the noble Baroness, Lady Verma. I was not able to note them all down or find all the answers in my brief, but I promise that I will write to her to answer all her questions.
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The review of the independent Child and Adolescent Mental Health Services was raised by my noble friend Lord Layard and other noble Lords. The review was commissioned by Ministers and reported in November 2008. It identified the need to reduce waiting times from referral to treatment. The Government have accepted this recommendation in principle and have already commissioned good practice guidance in this area. Taking work in this area forward will be a priority for the national support programme. It is indeed a priority for us and the proposals of my noble friend Lord Layard are being considered as part of this programme. I believe that he is also a member of that steering group.
The noble Baroness, Lady Meacher, raised the issue of PCTs being encouraged to provide CBT. The Government have already made that clear. We have encouraged PCTs to make CBT available where clinicians prescribe it for patients. We will continue to do so. I have already mentioned that CBT should be presented to patients as a treatment option only by trained therapies as part of an overall treatment package. It is worth noting—there was some discussion about this—that this is a process that empowers patients to make choices about the treatments that are right for them.
My noble friend Lord Rea asked a series of questions about IAPT services being available for people with serious health problems. The service provides treatment for people with common mental health problems from mild to moderate depression. But people with comorbid depression, other anxiety disorders and more severe and enduring mental health problems would be able to access IAPT services for their depression and anxiety disorders. Indeed, people with drug or alcohol problems would not be excluded from receiving evidence-based psychological therapies for their depression. Where PCTs—Liverpool, for example—have identified particular local needs for people with comorbid problems, they have targeted the new IAPT services on that population. The Government are providing significant funding for people with depression and anxiety disorders for access to those therapies.
My noble friend Lord Rea also raised the issue of investment. The noble Lord, Lord Carlile, spoke of
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The noble Countess, Lady Mar, made a very interesting and well informed speech about CFS/ME, whose sufferers she has championed for many years. I will be pleased to investigate the issues that she has raised about CFS/ME treatment, recommended by NICE. It is important to restate the value which the Government place on the independence of NICE’s evaluation process, but I undertake to follow up the disturbing point she made and see whether I can provide her with clarification.
The noble Lord, Lord Carlile, spoke with great wisdom about the different applications of CBT in many different settings, particularly for young people. I absolutely agree with him about the need for making CBT more available in young offender units. He is right to point out the need to roll this out in rural areas and across the UK.
Since October 2007, we have invested significantly in improving access to psychological therapies. I have already mentioned the amount to the noble Baroness, Lady Verma. Psychological therapies are expanding across the country and making one of the most significant improvements in our mental health services that we have seen in decades. The Government’s commitment to that is beyond doubt, as their level of investment demonstrates. The NHS’s commitment is similarly convincingly shown by the pace with which it is establishing these much needed services. Once again, I thank the noble Baroness for bringing this important topic to the attention of your Lordships’ House.
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